James Woods Sues After Brother Dies in ER

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medicinesux

medicinesux

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Wonder what the EKG showed? The anterior infarction he mentions may or may not have been real.

That's what I hate about computer interpretations of EKG's. They can be harmful sometimes. Especially the classic "non-specific T wave changes" or something like that. If something goes wrong, you're screwed (when in fact the vast majority of those non-specific changes are just that, non-specific and not related to ischemia or injury).
 
Never heard of this Woods dude. The jury will probably buy the argument here. I mean what's to dispute? The EKG machine made the diagnoses. Case closed.

I love how the reporter says, "And as the trial begain today, Woods leaned over and gave his nephew a....(pause, nods head with empathy and dramaticism, gave him what? A punch? A million dollars?), kiss on the cheek".
 
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willow18 said:
Never heard of this Woods dude. The jury will probably buy the argument here. I mean what's to dispute? The EKG machine made the diagnoses. Case closed.

I love how the reporter says, "And as the trial begain today, Woods leaned over and gave his nephew a....(pause, nods head with empathy and dramaticism, gave him what? A punch? A million dollars?), kiss on the cheek".
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Often times the machine interpretation isn't that great. I can't tell if you were being sarcastic or not. But it may not be case closed simply based on the machine interp.
 
atkinsje said:
Often times the machine interpretation isn't that great. I can't tell if you were being sarcastic or not. But it may not be case closed simply based on the machine interp.
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The machine often reads "Anterior infarct, age indeterminate" usually they are normal EKGs, or normal findings for that patient.
 
GeneralVeers said:
The machine often reads "Anterior infarct, age indeterminate" usually they are normal EKGs, or normal findings for that patient.
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That's exactly the problem with these computer interpretations of EKGs. There could be just tiny q waves in anterior leads and the interpretation can read "anterior infarct, age indeterminate" but the pt can have no symptoms or signs and markers can be fine. Then, if something goes wrong, the lawyer can point to the paper and say that the computer made the diagnosis and the doctor was wrong. I try not to even look at the machine's interpretation as they often are wrong and often miss things.

I don't know all of the details of the case, but the point is if in the eyes of the layperson all they will see is "the machine said what the problem was and it took the doctors 86 minutes to give appropriate care!!" Laypeople watch tv and not want something hi-tech a la CSI and so when they see some machine stating a diagnosis they will believe it more than the doctor who might say that the ECG had few non-specific ST-T changes, the pt had no CP/SOB/N/V/diaphoresis, VS stable, markers were WNL and pt's complaint was sore throat based on his H/P and clinical intuition. Especially in the case when a person goes into cardiac arrest soon thereafter. I think it's unlikely that if the ECG truly showed an acute anterior infarct that it would take physicians 86 minutes to start ACS protocol treatment and intervention.

I think what might have happened was a middle-aged male came to the ER with the complaint of sore throat. Maybe he had hx of cardiac dz and maybe not. Still, like some community hospitals, because of his age (regarless of CC) the pt got an ECG. Pt probably had no C/o CP or S/s of ACS and or down played any complaints. ECG might have said whatever the computer read it as but most likely an attending saw it and wasn't impressed and so based on his assessment there was no need to do send for enzymes and/or start BB, anticoagulation, ASA, call to cath lab, etc. and the pt probably had stable VS sitting there in the hallway or ED bed. Then maybe 1 hr goes by and for whatever reason the pt maybe has some CP and/or VS dropping or another s/s (for which they started meds) or just goes into Cardiac arrest and dies. I've seen these type of situation at a busy community ED a few times. It usually doesn't mean that the doctor missed something or was neglegent in any way... but to most people if you come in feeling OK and then leave dead, the doctor must have done something wrong.
 
atkinsje said:
Often times the machine interpretation isn't that great. I can't tell if you were being sarcastic or not. But it may not be case closed simply based on the machine interp.
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Yes; that was sarcasm. But on the issue you raised, while we obviously don't have the full facts before us (why did a grown man with a 'sore throat' go to an ED...?), lets say we have a middle aged man with a sore throat with avg risk of cardiac dz, would you have gotten an ECG?
 
willow18 said:
Never heard of this Woods dude.
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You've never heard of James Woods? He's not the most famous actor, but certainly has been in his share of movies and TV, and movies that are on cable all of the time.

I mean, I've never seen The Hills, but know who those people are, and have heard of (although never seen) Gossip Girl.
 
Apollyon said:
You've never heard of James Woods? He's not the most famous actor, but certainly has been in his share of movies and TV, and movies that are on cable all of the time.

I mean, I've never seen The Hills, but know who those people are, and have heard of (although never seen) Gossip Girl.
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Let's not forget the high school on Family Guy is named after him...not to mention he's made at least 2 guest appearances.
 
I'll confess - I read the computer interpretation. It's not like I don't look at the tracing too, but why ignore the benefit of a completely criteria-driven interpretation?

I suspect it wasn't a STEMI, or the lawyer would've said he was having an "ACUTE MYOCARDIAL INFARCTION" [echo effect on voice]. So, based on my admittedly incomplete information, my guess is that it wasn't so much a delay in diagnosis that was the problem here, but that the guy was on a hallway gurney without a monitor, and then went into a non-perfusing rhythm. I was ready to type that only patients with complaints like ankle sprain should be seen in hallway, non-monitored beds, but then I remembered that he was complaining of a sore effing throat. Yeah, so it turned out to be chest pain radiating to the jaw, but cripes! During the novel H1N1 pandemic when twice our normal census is presenting with far more frightening chief complaints every day it's inevitable that some atypical presentations are going to get lost in the shuffle. The American public's refusal/inability to understand this is one of the pillars of our "health care crisis".
 
willow18 said:
why did a grown man with a 'sore throat' go to an ED...?)
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'cause he was near my ED?

That seems to be more than enough to come in from my disappointing experience.

Take care,
Jeff
 
willow18 said:
Yes; that was sarcasm. But on the issue you raised, while we obviously don't have the full facts before us (why did a grown man with a 'sore throat' go to an ED...?), lets say we have a middle aged man with a sore throat with avg risk of cardiac dz, would you have gotten an ECG?
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Oh completely agree there isn't enough detail to know what really happened. I was simply commenting on what you have already said was sarcasm. I'm not too quick on picking up sarcasm on the interwebs. . .
 
WilcoWorld said:
I remembered that he was complaining of a sore effing throat. Yeah, so it turned out to be chest pain radiating to the jaw, but cripes!
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Did he actually complain of chest pain? It sounded like he had an anginal equivalent (the sore throat) and wasn't complaining of chest pain. The sore throat (the anginal equivalent) was the only thing that he was complaining of.
 
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http://www.popeater.com/2009/11/10/...ds-takes-hospital-to-trial-in-brothers-death/

Here's a link to an article about the case which has a little more information. According to the article, the pt had PMHx of HTN, Atheroslerosis, was overweight and suffered from myocardial ischemia. He presented c/o sore throat and vomiting, both of which could be a part of ACS presentation.

Again, I don't know the full HPI but given this hx, 49 y/o with sore throat and vomiting I'd order an ECG. Then I'd have to see the ECG and check on the pt to see if his symptoms are worsening to see if a workup is necessary.

I am not a lawyer but the hospital's defense seems a bit weak... "lawyers for the hospital say his heart and arteries were already so diseased that there was no way to save him and that he died before any potentially lifesaving measures could even have been taken." This argument doesn't answer why would you NOT start treatment, it only argues why the treatment might not work.
 
southerndoc said:
Did he actually complain of chest pain? It sounded like he had an anginal equivalent (the sore throat) and wasn't complaining of chest pain. The sore throat (the anginal equivalent) was the only thing that he was complaining of.
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I don't know if he actually complained of chest pain, but the way that I meant for my post to be interpreted was that his neck pain was an anginal equivalent, and that phrasing it as "sore throat" makes it a lot harder to pick up on than "neck pain" or "jaw pain" would be.
 
Glad to see my Emergency Dept. make it on Student Doctor....we've finally reached the big time! :D
 
Think about this - this could happen to any one of us at any time, and the legal judgment will have little to nothing to do with our clinical judgment. Sure, we all know about anginal equivalents, but in the absence of compelling data, symptoms, or exam findings in a patient who presented the way this one did, would any of us have honestly jumped to aspirin, nitrates, or oxygen? I initially read this thread knowing where it was going, but then realized that in reality, I would have probably done the same thing. In fact, it doesn't sound like I would have even gotten the EKG in the first place. If the patient had arrested without an EKG, would there even be any grounds for a case? I don't think so.

I guess in my rambling, my point is that sometimes we are too protocol- driven to be able to think clinically, and sometimes the protocols we have in place are conflicting with each other. It was likely a combination of the protocol that ordered the EKG in triage, the protocol that triaged that patient to minor care for sore throat, and the automatic criteria-based printout on the EKG that landed this patient in the morgue and the case in court.

It is hopeful that, in the case of Woods, who is a highly intelligent individual btw, this case will be brought to light as an example of what may lie ahead for our country's future. As pressure rises to give efficient care, reduce hospital admissions, control costs, and reduce the workforce driving up hospital costs, there will be more and more protocols to drive patient care.

I wish that hospital and its staff the best of luck, and hope that this serves as a wake-up call for everyone in health care.
 
NinerNiner999 said:
Think about this - this could happen to any one of us at any time, and the legal judgment will have little to nothing to do with our clinical judgment. Sure, we all know about anginal equivalents, but in the absence of compelling data, symptoms, or exam findings in a patient who presented the way this one did, would any of us have honestly jumped to aspirin, nitrates, or oxygen?
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This is the problem (OK, one of many) with our system. We've equated bad outcome with malpractice.

For the past twenty or so years, we've been going bongo ape-**** trying to catch every last silent MI. The result is that we now admit everyone with any symptom between their knees and chin and give them a huge workup to catch disease everyone highly suspects isn't there. You know, just to be sure.

The result of this massive increase in workups? We still miss exactly the same number of MIs.

This is almost a definitional thing. Silent MIs are called 'silent' for a reason. They're undiagnosable. No matter what we do, we're going to miss a small percentage of MIs. This isn't malpractice, it's reality.

Take care,
Jeff
 
Jeff698 said:
This is almost a definitional thing. Silent MIs are called 'silent' for a reason. They're undiagnosable. No matter what we do, we're going to miss a small percentage of MIs. This isn't malpractice, it's reality.
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Very good point. I wish the public understood this. There is also the reality that people can have strep throat AND an MI. When the 85 year old who has been smoking for 40 years comes in with back pain, or cough, or whatever, and they die 2 days later, we get blamed for their death. Nobody understands that certain people, whether because of their genetics, or their life choices, are ticking time-bombs, just waiting to keel over dead despite what we do. The fact that they had a sore neck, back pain, or toe pain prior to their death may be just a coincidence.
 
This brings up a good point. How many of you are at places where techs and nurses do an ECG on someone without an order just because they want to, and how often do you find it in the back of the paper chart when you are finalizing the chart? Maybe it's just a problem in general but one place I work can't seem to institute the simple policy of putting an ECG directly into the physician's hand at the time it is done. I actually can't stand any orders being placed without me requesting them as I find the desire to expedite care rarely provides a real benefit in the end.
 
We have a policy that all EKG's must be shown immediately to the ER doc. Nurses can get EKG's on anybody they want. Often times they aren't necessary (fever, chest pain only when coughing), but I've seen some that I normally wouldn't order an EKG on have real pathology that has lead to a serious diagnosis (i.e., atypical chest pain that's reproducible with no PE risk factors, but diagnosed with PE after ordering a CT based solely on EKG findings).

My group has agreed on nurse-initiated order sets. If a pregnant woman presents with abdominal pain, vaginal bleeding, etc., and the expected wait before physician evaluation is >20 minutes, then the nurse initiates the order set (in this case CBC, beta-HCG, UA, type/Rh if not known, and transpelvic ultrasound). Similar order protocols exist for chest pain (atypical), chest pain (cardiac risk factors), lower and upper abdominal pain, trauma, etc. Overall, I've found it really decreases total time in the department, which we have measures to adhere to (door-to-door time less than 180 minutes, door-to-floor less than 240 minutes).
 
We have standing orders for an EKG on any chest pain patient and nurses may order EKGs on patients as well. However, the tech or nurse must immediately bring the EKG to attending or 3rd year resident to be reviewed. They also print out a copy of the most recent old EKG if there is one. I have seen several STEMIs caught in patients with a very atypical presentation as a result.
 
southerndoc said:
Nurses can get EKG's on anybody they want. Often times they aren't necessary (fever, chest pain only when coughing), but I've seen some that I normally wouldn't order an EKG on have real pathology that has lead to a serious diagnosis (i.e., atypical chest pain that's reproducible with no PE risk factors, but diagnosed with PE after ordering a CT based solely on EKG findings).
Click to expand...

More testing, more pathology -> not necessarily better outcomes, e.g.: Computed tomography imaging in the management of headache in the emergency department: cost efficacy and policy implications. PMID: 19397223
$75k per significant finding - debatably, all of which might appropriately be discovered on an outpatient CT ordered by a PMD.

More testing on low- or no-risk patients, such as discovering the pulmonary embolism and condemning him to potentially risky anticoagulation and the risk of ARF from the IV contrast - in someone who clearly wasn't clinically ill enough for you to worry about PE - might not have been the best thing for him/her.

Just a random argumentative thought....
 
I would rather spend money on unnecessary testing than $1 million on a judgement against me for missing something.

Like you, I was all into evidence-based medicine as a resident. Get out in the real world where patient satisfaction scores translate into whether you have a job or not, coupled with the real risk of litigation, and you'll soon practice under a patient-centered, defensive medicine concept. If you don't, you'll either hear from your medical director about poor patient satisfaction scores or you'll hear from an attorney. Yes, you may can defend not ordering an x-ray on someone who didn't meet Ottawa ankle rules, but as one physician I know put it, it works great in Ottawa, but not in the US. You're responsible for missing something whether you follow the evidence or not.
 
southerndoc said:
Overall, I've found it really decreases total time in the department, which we have measures to adhere to (door-to-door time less than 180 minutes, door-to-floor less than 240 minutes).
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Door-to-floor <240 minutes?

Tell us about this. What a cool concept. Whose guideline is this and how is it enforced?

Take care,
Jeff
 
Jeff698 said:
Door-to-floor <240 minutes?

Tell us about this. What a cool concept. Whose guideline is this and how is it enforced?

Take care,
Jeff
Click to expand...
Pushed by the CEO of our health system. Docs have to call back within 15 mins of being paged. If it's a sure admission, we fill out bridging orders BEFORE the doc calls back to facilitate a bed.

It's a new measure we started a few months ago. Goal is 80% target. Right now we're at 70% (not bad).
 
southerndoc said:
Pushed by the CEO of our health system. Docs have to call back within 15 mins of being paged. If it's a sure admission, we fill out bridging orders BEFORE the doc calls back to facilitate a bed.

It's a new measure we started a few months ago. Goal is 80% target. Right now we're at 70% (not bad).
Click to expand...

Initiatives like this have to come from the top down. Patient flow is an entire hospital commitment, not just and ED commitment. Nice to see a CEO "get it."
 
WakeMedHeel said:
Initiatives like this have to come from the top down. Patient flow is an entire hospital commitment, not just and ED commitment. Nice to see a CEO "get it."
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I work in a similar nirvana. Our CEO helps move the meat for us. We basically never board patients our EDs flow and the nurses and techs are there to assist physicians (not do what they want).

I mean I loved residency but from a patient centered approach we move the meat and dont get stuck watching patients for 1-2 days.

I moonlit and this job I got is the cats meow!! somehow our health system makes money doing this too!
 
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